County Needs Assessment
Sponsored By CHANGE, Inc. Community Action Agency
1. What county do you live in? 
If Other, Please List:
2. Check if the following are needs for you or your family.
3. Please list any additional needs you or your family has that were not listed above.
4. Check how much of a problem the following barriers are to you and your family in seeking/gaining assistance with your basic needs.
Can’t Afford Fees/Costs of Assistance
Not Eligible/Don’t Qualify For Assistance
No Transportation To/For Assistance
Don’t Know Where To Go For Help
Pride (Don’t Want To Ask For Help)
Programs/Services Not Available
in My Area
No Childcare While
Receiving/Obtaining Assistance
Prior Bad Experience With
Service/Program
Have To Work During Service Hours
Health/Disability
5. How many children do you have? Children Living In Household?
6. Are you a single parent?
7. What are your barriers to childcare services? (Check All That Apply)
8. How many household members do NOT currently have health insurance?
(Including Medicare, Medicaid, CHIP, Private Insurance)
9. Of those with NO health insurance, how many are: Under 18: Over 65:
10. What are your barriers to health care? (Check All That Apply)
11. Were you able to receive dental care in the last year?
12. Why did you not receive dental care in the last year? (Check All That Apply)
13. What is your Employment Status?
14. What are your barriers to employment? (Check All That Apply)
15. Do you have reliable Transportation?
16. What are your barriers to reliable transportation? (Check All That Apply)
17. Are your housing conditions adequate?
18. Do you own your home?
20. What are your major housing concerns? (Check all that apply)
22. Have you ever used one of CHANGE, Inc.'s services?
23. Please pick the appropriate response under each demographic heading.
24. Pick The Highest Level of Education You Have Completed.
Please answer the following questions, and click submit.
Or the survey out and mail it to CHANGE, Inc. 3136 West Street Weirton, WV 26062 Attn: Lisa
